- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,862.09 / $2,511.89
| Professional | | $1,659.59 | $1,862.09 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,585.78 / $9,120.11
| Professional | | $4,897.79 | $7,585.78 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,090.30 / $5,888.44
| Professional | | $1,905.46 | $3,090.30 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,162.28 / $6,309.57
| Professional | | $1,949.84 | $3,162.28 | $6,309.57 |